Ch 49 Endocrine- Nursing Care Plans Etc PDF

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Nursing care plans for endocrine problems. Hopefully this will help you in your studies and in you clinical. Enjoy...

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eNursing Care Plan 49-1 Patient with Hyperthyroidism Nursing Diagnosis* Activity Intolerance Etiology: Fatigue, exhaustion, and heat intolerance from hypermetabolism Supporting data: Reports of weakness, inability to perform usual activities, dyspnea, tachycardia, irritability Patient Goals 1. Achieves a program of activity that balances physical activity with energy-conserving activities 2. Reports increased tolerance to activity with less weakness and fatigue Outcomes (NOC) Psychomotor Energy  Exhibits concentration _____  Maintains personal grooming and hygiene _____  Exhibits stable energy level _____  Exhibits ability to accomplish daily tasks _____ Energy Conservation  Balances activity and rest _____  Recognizes energy limitations _____  Uses energy conservation techniques _____  Reports adequate endurance for activity _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated

Interventions (NIC) and Rationales Energy Management  Monitor patient for evidence of excess physical and emotional fatigue because hyperthyroidism results in protein catabolism, overactivity, and increased metabolism leading to exhaustion.  Monitor cardiorespiratory response to activity (e.g., tachycardia, other dysrhythmias, dyspnea, diaphoresis, pallor, blood pressure [BP], and respiratory rate) because decompensation of cardiopulmonary function can occur with hypermetabolism.  Assist with regular physical activities (e.g., ambulation, transfers, turning, and personal care) to make certain patient’s daily needs are met.  Assist the patient to understand energy conservation principles (e.g., the requirement for restricted activity or bed rest) to avoid fatiguing patient.  Assist the patient to schedule rest periods.  Avoid care activities during scheduled rest periods to promote adequate rest.

*Nursing diagnoses listed in order of priority. Copyright © 2020 by Elsevier, Inc. All rights reserved.

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Nursing Diagnosis Impaired Nutritional Status Etiology: Hypermetabolism, inadequate food intake Supporting data: Weight loss; less than optimal body weight, activity intolerance Patient Goals 1. Maintains weight appropriate for height (target weight ____ lb/kg) 2. Consumes food and fluid adequate to meet nutritional needs 3. Corrects nutritional deficiencies Outcomes (NOC) Nutritional Status  Nutrient intake _____  Food intake _____  Fluid intake _____  Energy _____  Weight/height ratio _____  Hydration _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range

Interventions (NIC) and Rationales Nutrition Management  Determine, in collaboration with the dietitian, the number of calories and type of nutrients needed to meet nutrition requirements.  Determine patient’s food preferences to determine extent of the problem and plan appropriate interventions.  Adjust diet, as necessary (i.e., high-protein, highcalorie, nutritious foods and drinks that can be readily consumed) because hyperthyroidism increases metabolic rate with resulting need to prevent muscle breakdown and weight loss.  Offer nutrient-dense snacks to maintain adequate caloric intake.  Monitor calorie and dietary intake to evaluate nutritional status.  Monitor trends in weight gain and loss to evaluate effectiveness of nutritional plan.  Teach patient about nutritional needs (i.e., discuss dietary guidelines, MyPlate) to promote self-care.  Assist the patient in accessing community nutritional programs.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

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eNursing Care Plan 49-2 Patient with Hypothyroidism Nursing Diagnosis* Obesity Etiology: Calorie intake in excess of metabolic rate Supporting data: Weight gain in presence of decreased appetite Patient Goals 1. Attains weight appropriate for height (target weight _____ lb/kg) 2. Maintains caloric intake that meets nutritional needs Outcomes (NOC) Weight Maintenance Behavior  Monitors body weight _____  Maintains recommended eating pattern _____  Balances exercise with caloric intake _____  Maintains optimal daily caloric intake _____  Maintains optimum weight _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated

Interventions (NIC) and Rationales Weight Management  Discuss with patient the medical conditions that may affect weight to reassure patient that optimal weight can be maintained with treatment of hypothyroidism.  Discuss with patient the relationship between food intake, exercise, weight gain, and weight loss to promote understanding of weight management.  Determine the patient’s ideal body weight to maintain appropriate BMI for patient.  Assist in developing well-balanced meal plans consistent with level of energy expenditure.  Develop with the patient a method to keep a daily record of intake, exercise sessions, and/or changes in body weight to promote progress toward final goal. Nutrition Management  Determine, in collaboration with dietitian, number of calories and type of nutrients needed to meet nutrition requirements.  Teach patient about nutritional needs (i.e., discuss dietary guidelines and food pyramids) so patient will be more agreeable to dietary restrictions.  Monitor calorie and dietary intake to evaluate patient’s management of nutrition.  Monitor trends in weight gain and loss to monitor progress toward target weight.

*Nursing diagnoses listed in order of priority. Copyright © 2020 by Elsevier, Inc. All rights reserved.

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Nursing Diagnosis Constipation Etiology: Decreased motility of gastrointestinal tract Supporting data: Decrease in stool frequency and/or volume; hard, dry stools; severe flatus; abdominal distension Patient Goal Has regular, soft formed stools that are easy to pass Outcomes (NOC) Bowel Elimination  Elimination pattern _____  Stool soft and formed _____  Ease of stool passage _____  Passage of stool without aids _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised

Interventions (NIC) and Rationales Constipation/Impaction Management  Encourage increased fluid intake to maintain soft stool.  Teach patient and caregivers about high-fiber diet to increase knowledge of how to increase fecal mass.  Monitor bowel movements, including frequency, consistency, shape, volume, and color to plan appropriate interventions.  Suggest use of laxatives/stool softeners to stimulate bowel evacuation.  Teach patient and caregivers about timeframe for resoluting constipation because elimination patterns will improve with treatment of hypothyroidism.

Nursing Diagnosis Acute Confusion Etiology: Slowed mental processes Supporting data: forgetfulness, memory loss, somnolence, personality changes Patient Goal Has cognitive orientation with correction of hormone deficiency Outcomes (NOC) Cognition  Comprehension of the meaning of situations _____  Attentiveness _____  Concentration _____  Recent memory _____  Cognitive orientation _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised

Interventions (NIC) and Rationales Reality Orientation  Monitor for changes in orientation, cognitive and behavioral functioning, and quality of life to determine appropriate interventions.  Orient patient to person, place, and time as needed to decrease confusion.  Adapt human and environmental sensory stimuli (e.g., visiting sessions, sights, sounds, lighting, smells, and tactile stimulation) based on patient’s needs as disorientation is increased by overstimulation.  Speak to patient in a distinct manner with an

Copyright © 2020 by Elsevier, Inc. All rights reserved.

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4 = Mildly compromised 5 = Not compromised

appropriate pace, volume, and tone to allow patient to understand.  Avoid frustrating the patient by demands that exceed capacity (e.g., abstract thinking when patient can think only in concrete terms, decision making beyond preference or capacity) to decrease frustration and loss of self-esteem.  Use environmental cues (e.g., signs, pictures, clocks, calendars) to stimulate memory, maintain orientation, and promote appropriate behavior.

Nursing Diagnosis Fatigue Etiology: Decreased metabolic rate, anemia, decreased cardiac output, neurologic changes Supporting data: Increase in rest requirements, lack of energy, lethargy, disinterest in surroundings, reports of an overwhelming lack of energy Patient Goals 1. Takes part in self-care activities of daily living with minimal discomfort and fatigue 2. Reports increased energy and endurance Outcomes (NOC) Fatigue Level  Exhaustion _____  Lassitude _____  Impaired concentration _____  Decreased motivation _____  Depressed mood _____  Post-exertional malaise _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None

 Activities of daily living _____  Rest quality _____  Sleep quality _____  Alertness _____

Interventions (NIC) and Rationales Energy Management  Assess patient’s physiologic status for deficits resulting in fatigue to determine extent of problem and plan appropriate interventions.  Monitor patient for evidence of excess physical and emotional fatigue to evaluate effectiveness of treatment.  Monitor cardiorespiratory response to activity (e.g., pulse rate, cardiac rhythm, respiratory rate) to determine effect of activities and plan activity increases.  Encourage alternate rest and activity periods to prevent fatigue.  Teach activity organization and time-management techniques to prevent fatigue.  Promote bed rest/activity limitation (e.g., increase number of rest periods) to improve patient’s tolerance and comfort level.  Plan activities for periods when the patient has the most energy to allow maximum participation.  Monitor/record patient’s sleep pattern and number of sleep hours as sleep patterns are often altered in

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 Balance of activity and rest _____  Metabolism _____

fatigue.

Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised

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eNursing Care Plan 49-3 Patient with Cushing Syndrome Nursing Diagnosis* Risk for Infection Risk factors: Lowered resistance to stress and suppression of immune system Patient Goal Has no signs or symptoms of infection Outcomes (NOC) Infection Severity  Fever _____  Sputum culture colonization _____  Urine culture colonization _____  Blood culture colonization _____  Wound site culture colonization _____  White blood count elevation _____  Pain/tenderness _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None

Risk Control  Modifies lifestyle to reduce risk _____  Avoids exposure to health threats _____

Interventions (NIC) and Rationales Infection Protection  Monitor for systemic and localized signs and symptoms of infection so infection can be detected early and treatment initiated promptly.  Provide private room.  Maintain asepsis for patient at risk.  Screen all visitors for communicable diseases to reduce the risk of infection exposure.  Monitor absolute granulocyte count, WBC count, and differential results to detect infection and plan treatment.  Obtain samples for culture as indicated to identify and treat infectious organisms.  Inspect skin and mucous membranes for redness, extreme warmth, or drainage because other signs and symptoms of infection may be minimal or absent.  Teach patient and family members how to avoid infections (e.g., hand washing).  Teach the patient and family about signs and symptoms of infection and when to report them to the health care provider.

Measurement Scale 1 = Never demonstrated 2 = Rarely compromised 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated

*Nursing diagnoses listed in order of priority. Copyright © 2020 by Elsevier, Inc. All rights reserved.

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Nursing Diagnosis Obesity Etiology: Increased appetite, high caloric intake, and inactivity Supporting data: Reports of increased appetite; weight 20% or more than optimum for height Patient Goals 1. Attains weight appropriate for height (target weight _____ lb/kg) 2. Maintains low-calorie diet that meets nutritional needs Outcomes (NOC) Nutritional Status  Nutrient intake _____  Food intake _____  Weight/height ratio _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range

Knowledge: Prescribed Diet  Prescribed diet _____  Benefits of diet _____  Relationship among diet, exercise, and weight _____  Strategies to change dietary habits _____

Interventions (NIC) and Rationales Nutrition Management  Determine, in collaboration with dietitian, number of calories and type of nutrients needed to meet nutrition requirements (e.g., high protein, low fat, low carbohydrate, low sodium, high potassium, high calcium) to help correct the effects of excess corticosteroids.  Teach patient about nutritional needs (i.e., discuss dietary guidelines and food pyramids) to promote selfcare.  Monitor calorie and dietary intake.  Monitor trends in weight gain and loss to evaluate progress toward goal. Nutritional Counseling  Discuss patient’s knowledge of the food groups, as well as perceptions of the needed diet modification.  Evaluate progress of dietary modification goals at regular intervals.  Provide referral/consultation with other members of the health care team (e.g., dietitian, physical therapist) to help address weight gain, muscle wasting, and altered mineral levels.

Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge

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Nursing Diagnosis Disturbed Body Image Etiology: Altered body image, emotional lability, diminished physical capabilities Supporting data: States negative feelings about personal appearance and inability to perform usual activities Patient Goals 1. Reports increased acceptance of appearance 2. Uses self-care methods to improve appearance Outcomes (NOC) Self-Esteem  Acceptance of selflimitations _____  Description of self _____  Maintenance of grooming/hygiene _____  Acceptance of compliments from others _____  Description of pride in self _____  Feelings about self-worth _____  Fulfillment of personally significant roles _____

Interventions (NIC) and Rationales Self-Esteem Enhancement  Encourage patient to identify strengths to promote awareness of capabilities.  Reinforce the personal strengths that patient identifies.  Make positive statements about the patient to boost morale by providing positive feedback.  Encourage increased responsibility for self to improve patient’s appearance and self-esteem. Teaching: Disease Process  Provide reassurance about patient’s condition (e.g., explaining physical and emotional changes will resolve with hormonal balance) to increase patient’s understanding and assist with coping.

Measurement Scale 1 = Never positive 2 = Rarely positive 3 = Sometimes positive 4 = Often positive 5 = Consistently positive

Nursing Diagnosis Risk for Impaired Tissue Integrity Risk factors: thin fragile skin, edema, redistribution of fat, and impaired healing Patient Goal Has no skin impairment and maintains intact skin Outcomes (NOC) Tissue Integrity: Skin and Mucous Membranes  Skin integrity _____  Thickness _____  Texture _____

Interventions (NIC) and Rationales Skin Surveillance  Observe extremities for color, warmth, swelling, pulses, texture, edema, and ulcerations for early detection of skin impairment.  Monitor for sources of pressure and friction to prevent

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 Elasticity _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised

 Skin lesions _____  Abnormal pigmentation _____  Erythema _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None

injury to easily traumatized tissue.  Monitor skin for rashes and abrasions to promote early treatment.  Monitor skin and mucous membranes for areas of discoloration, bruising, and breakdown to provide early treatment.  Document skin or mucous membrane changes to provide early intervention. Skin Care: Topical Treatments  Provide support to edematous areas to promote circulation to edematous areas.  Use devices on the bed (e.g., sheepskin) that protect the patient.

Copyright © 2020 by Elsevier, Inc. All rights reserved....